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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006264
Report Date: 03/22/2024
Date Signed: 03/22/2024 12:12:31 PM


Document Has Been Signed on 03/22/2024 12:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:IRVINE COTTAGE #4FACILITY NUMBER:
306006264
ADMINISTRATOR:WALTERS,KIMBERLYFACILITY TYPE:
740
ADDRESS:7 PRINCETONTELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kimberly Arnett - Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Andrea Mendivil and Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents and has 5 residents during today's visit. The Administrator has an Administrator Certificate expiring on 07/21/2024. Administrator Kimberly Arnett ,Compliance Manager Michelle Nesbitt, Tammy Sampedro Executive Administrator arrived shortly after.

LPAs Mendivil and Tea along with the Administrator toured the facility at 9:30 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, 1 staff bedroom, 2 resident bathrooms, living room, dining room, and kitchen. At ,10:00AM LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 125 degrees and 127 degrees with signage in both bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies in the garage. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. At 10:30 AM, LPA observed secured medications in a cabinet. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating and the exit gate is self latching and operational. LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provides activities in the form of games and exercise.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRVINE COTTAGE #4
FACILITY NUMBER: 306006264
VISIT DATE: 03/22/2024
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At 9:00AM, LPA Mendivil reviewed five resident files and 5 staff files. Residents files and staff files contained all required documentation. At 11:30 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2